Provider Demographics
NPI:1548996879
Name:MOORE, DEJUAN JP (RD, RDN)
Entity type:Individual
Prefix:
First Name:DEJUAN
Middle Name:JP
Last Name:MOORE
Suffix:
Gender:M
Credentials:RD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PISGAH CHURCH ROAD PMB 321
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2590
Mailing Address - Country:US
Mailing Address - Phone:336-609-0963
Mailing Address - Fax:
Practice Address - Street 1:415 PISGAH CHURCH ROAD PMB 321
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2590
Practice Address - Country:US
Practice Address - Phone:336-609-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006686133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered